What is the best approach to adjust the Lantus (insulin glargine) dose in a patient with elevated Hemoglobin A1c (HbA1c) level, taking Janumet (sitagliptin/metformin) and Jardiance (empagliflozin)?

From the Guidelines

The patient's Lantus dose should be increased by 2-4 units once weekly, based on fasting blood glucose levels, until the target fasting glucose of 80-130 mg/dL is achieved, as recommended by the most recent guidelines 1. To adjust the Lantus dose in a patient with elevated HbA1c who is already on Janumet and Jardiance, a systematic titration approach should be implemented.

Key Considerations

• The current Lantus dose of 10 units should be increased by 2-4 units once weekly until the target fasting glucose is achieved.
• For patients new to insulin, beginning with 10 units daily, preferably at bedtime, is a common approach, as suggested by earlier guidelines 1.
• However, the most recent guidelines from 2025 1 emphasize the importance of individualized treatment goals and the incorporation of high-glycemic-efficacy therapies, which may reduce the need for insulin intensification.
• Monitoring fasting glucose daily and adjusting the dose accordingly is crucial:
  • If readings remain above 130 mg/dL for three consecutive days, increase the dose by 2 units.
  • If below 80 mg/dL or hypoglycemia occurs, decrease the dose by 2-4 units.

Combination Therapy

• Continue the patient's Janumet and Jardiance as prescribed, as these medications work synergistically with insulin through different mechanisms.
• Janumet improves insulin sensitivity and reduces hepatic glucose production.
• Jardiance promotes urinary glucose excretion.

Follow-up and Adjustments

• Regular follow-up every 2-3 months with HbA1c testing is essential to evaluate the effectiveness of this regimen and make further adjustments as needed, considering the patient's individualized treatment goals and response to therapy 1.

From the FDA Drug Label

Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), during acute illness, or changes in renal or hepatic function. Dosage adjustments should only be made under medical supervision with appropriate glucose monitoring [see Warnings and Precautions (5.2)]. Individualize and adjust the dosage of Insulin Glargine based on the patient's metabolic needs, blood glucose monitoring results and glycemic control goal.

The patient's HbA1c level is 12.3, indicating poor glycemic control. To adjust the Lantus (insulin glargine) dose, consider the following:

• Blood glucose monitoring results should guide dosage adjustments.
• Glycemic control goal should be individualized based on the patient's metabolic needs.
• Increasing the Lantus dose to 20 units may be considered, but only under medical supervision with appropriate glucose monitoring.
• The decision to increase the dose should be based on the patient's metabolic needs, blood glucose monitoring results, and glycemic control goal 2.

Key considerations:

• Monitor blood glucose levels closely when adjusting the insulin dose.
• Adjust the dose based on the patient's individual needs and response to therapy.
• Medical supervision is necessary when making dosage adjustments.

From the Research

Adjusting Lantus Dose in a Patient with Type 2 Diabetes

• The patient's current HbA1c level is 12.3%, indicating poor glycemic control 3.
• The patient is currently taking Lantus 10 units, Janumet 50/1000 mg BID, and Jardiance 10 mg daily.
• Increasing the Lantus dose to 20 units may be considered to improve glycemic control, but it is essential to weigh the potential benefits against the risks of hypoglycemia 4.
• A study on the triple combination of insulin glargine, sitagliptin, and metformin in type 2 diabetes found that adding glargine to metformin-sitagliptin therapy resulted in a significant reduction in HbA1c levels, but also increased the risk of hypoglycemia 4.

Considerations for Adjusting the Lantus Dose

• The patient's high HbA1c level indicates a need for improved glycemic control, but the risk of hypoglycemia must be carefully managed 5.
• The addition of empagliflozin to metformin has been shown to offer benefits in terms of decreasing asprosin levels and improving certain metabolic parameters in patients with type 2 diabetes 6.
• However, the study on the role of hemoglobin A1c in the assessment of diabetes and cardiovascular risk suggests that the HbA1c target should be personalized according to the risks and benefits of glycemic control 3.
• There is no direct evidence to support increasing the Lantus dose to 20 units in this patient, and any adjustments should be made with caution and close monitoring of blood glucose levels.

Potential Risks and Benefits

• Increasing the Lantus dose may improve glycemic control, but it also increases the risk of hypoglycemia 4.
• The patient's current medication regimen, including Janumet and Jardiance, may also contribute to the risk of hypoglycemia 6.
• Careful consideration of the potential risks and benefits, as well as close monitoring of blood glucose levels, is essential when adjusting the Lantus dose 5, 3.